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DOI: 10.1055/s-0040-1710041
Maternal Mortality: An Eco-Social Phenomenon that Calls for Systemic Action
Mortalidade Materna: Um Fenômeno Eco-Social que Demanda Ação SistêmicaPublication History
Publication Date:
24 April 2020 (online)
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Pregnancy, childbirth, and the postpartum period are phases commonly associated with joy and hope. Even though it may be an unplanned event for many women, pregnancy usually develops without complications most of the times: mother and newborn child start together—and well—a new phase of their lives. This does not mean that the good outcome was achieved without a significant number of women experiencing discomfort, stress, anxiety, fear, or even some sadness. These are conditions that, although not desirable, tend to be present during pregnancy, childbirth, and the postpartum period. However, for some women, this is a period of great anguish, suffering, and risk. Risk of intimate partner violence, of mistreatment in health facilities, of developing physical or psychological sequelae, and risk of dying.[1] [2] [3] [4]
A maternal death is an individual, family, and social tragedy. Because it is preventable in the absolute majority of times it occurs, there is no male equivalent, and it disproportionately affects certain groups of women, maternal mortality exceeds the boundaries of clinical obstetrics and reflects broader societal issues.[5] [6] [7] While hypertensive complications, bleeding, infection, unsafe abortion, and worsening of preexisting diseases are the main biomedical causes of maternal mortality, tackling it requires broader actions.[8] [9]
Considered as causes of complications of pregnancy, intrinsic or extrinsic etiological agents (such as uterine atony or bacterial infection) do not act in isolation on women to produce complications. The etiological agents act under the influence of several other factors, in a complex and multifactorial process known as the health-disease process ([Fig. 1]). Over thousands of years, the characteristics of the environment favored the evolution of current human beings. Among the innate characteristics and potential of Homo sapiens, lies the biological basis of pregnancy and childbirth. This includes, for instance, the shape of the pelvis and the complex endocrinology of parturition. The innate characteristics and potential of the species favored the development, over time, of the current human culture and society. Culture and society are the origin of the guiding principles of social organization, the legal and political structure, and the mode of production of the economy. In this context, human interaction with the planet has produced environmental degradation, with consequences that include the increasing concentration of particulate matter in the atmosphere and the acceleration of global warming. The latter, besides being responsible for the melting of ice glaciers and the rise of the sea level, is associated with a greater frequency and intensity of extreme climate events, including heat waves or drought or severe storms and heavy rain. These events affect maternal health and have been associated with an increased maternal and perinatal morbidity and mortality.[7] [10]
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Together, the innate characteristics of H. sapiens, their culture and society, and the environment are super determinants of the whole health-disease process, thus originating the so-called primary determinants of health. Education, income, ethnicity and gender issues affect the risk of a woman dying during pregnancy, childbirth, and postpartum/postabortion period. Women of color, those living on the outskirts of large cities or in rural areas, those with little access to education or income, are the women experiencing the highest maternal mortality.[6] Women deprived of their liberty, migrant women, women victims of trafficking and women in prostitution are frequently invisibilized and subject of additional marginalization and risk. The factors arising from or associated with the global climate emergency (e.g., extreme weather, heat stress, poor air quality, or changing distribution of infectious disease vectors) must also be highlighted.[10] [11] [12] Under the influence of these determinants, the individual, family and community characteristics give rise to lifestyle patterns, which may accentuate or reduce risks. Likewise, the family and community organization can act as a protection and support network for women, reducing the risk of mortality, or, on the contrary, favoring harmful lifestyles. Also coming from the principles and structures of society, social facilities (such as schools and the health system itself) undertake processes and practices capable of functioning as protective factors, mitigating the negative effects of the primary determinants and enhancing their positive effects. On the other hand, by becoming permeable to structural bias, health and social facilities risk reproducing violence, including abuse, disrespect and mistreatment of women during pregnancy, childbirth, and in the postpartum/postabortion period.
Given the broad determinants of maternal mortality and the complex health-disease process, maternal mortality has long ceased to be “just” a health indicator and became a social development indicator. Hence its inclusion as a progress indicator of two successive global initiatives, the Millennium Development Goals (2000–2015) and the Sustainable Development Goals (2016–2030). Both initiatives, promoted by the United Nations (UN), seek to encourage the governments of the signatory countries to implement programs to promote social development and eliminate extreme poverty.[13]
The World Health Organization (WHO) estimates that in the early 1990s there were ∼ 500,000 maternal deaths per year worldwide. According to the UN health agency, the annual number of maternal deaths around the world would be just over 450,000 deaths in 2000 and 295,000 in 2017. The global maternal mortality ratio in 2000 and 2017 was estimated at 342 and 211 maternal deaths per 100,000 live births, respectively. In Brazil, the maternal mortality ratio in 2000 was estimated by the WHO at 69 deaths per 100,000 live births, and, in 2017, 60 deaths per 100,000 live births. The WHO estimated for 2017 a total of 1,700 maternal deaths in Brazil, with the lifetime risk of 1 maternal death for 940 women.[14] There is some methodological difficulty in generating reliable global estimates over time, and all these estimates have a relatively wide range of unreliability. The Brazilian Ministry of Health generates its own estimates of maternal mortality. Although the estimates are compatible, considering their degree of uncertainty, the maternal mortality ratio estimated by the Brazilian Ministry of Health is slightly higher than that estimated internationally (64 maternal deaths per 100,000 live births in 2017). Within the scope of the Sustainable Development Goals, the target is to achieve a global maternal mortality ratio of 70 maternal deaths per 100,000 live births in 2030. For the global target to be achieved, each country needs to contribute to a certain reduction in mortality. For Brazil, the target maternal mortality ratio for 2030 is 30 maternal deaths per 100,000 live births.[15]
Considering the evolution of the maternal mortality ratio in Brazil since 1990, the most substantial reduction took place in the last decade of the 20th century. This reduction of maternal mortality has been partially and ecologically attributed to a greater access to primary health care during pregnancy (i.e., antenatal care), greater coordination between the different levels of the health system, and improvements in emergency services. These advances occurred in the context of greater economic stability and the implementation of the Unified Health System (SUS) in Brazil, which occurred in the beginning of the 1990s. In the 2000s, the rate of reduction in the maternal mortality ratio decreased and started to tend to stability, suggesting the need for more intense social transformations as well as greater gains in efficiency and quality in the health system.[15] [16]
Although there is no shortcut to reduce maternal mortality—social development is necessary for substantial and sustainable gains—the health sector cannot be exempted from its central role in tackling maternal mortality. The reduction in maternal mortality occurs over a long journey, which can be divided into stages. According to the theory of obstetric transition ([Box 1]), Brazil is between stages III and IV of this transition.[17] At this point, although issues of access to health care may persist, the quality of care becomes a major determinant of pregnancy outcomes. Eliminating delays within the system itself becomes a priority. It is important to note an apparent contradiction: while maternal mortality is largely preventable, a sizable number of women will experience complications almost inevitably. The preventability of some of the main complications (for example, preeclampsia and postpartum hemorrhage) has limitations, and their prompt recognition and proper management are essential. Thus, delays in recognizing complications by women themselves or health professionals, in the decision to seek help, in obtaining access to the health system, as well as in receiving adequate, respectful and quality care in health facilities become significant determinants of maternal mortality. In this context, health and social facilities—particularly the health system—function as safeguards and protection networks: the ability to neutralize the negative effects of primary determinants can be a measure of their efficiency, whereas the system's permeability to the primary determinants can indicate the opposite. Thus, it is essential that structuring actions are implemented and developed with a goal to strengthen the health system and reduce the system response time ([Box 2]).[9] [17] [18] [19]
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